Mercy Retirement & Care Center

In the surveyor’s words

From the most serious findings on record at Mercy Retirement & Care Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF689Jun 9, 2023

  Based on observation, interview, and record review, the facility failed to maintain safe water temperature for facility residents when hot water temperature from faucets in 31 of 31 bathrooms in resident rooms, and one of one resident shower room measured between 134 to 151.5 degrees Fahrenheit ( F). The facility had 26 of 56 residents (Residents 1, 2, 3, 7, 10, 16, 18, 19, 22, 27, 28, 30, 32, 33, 36, 37, 38, 42, 43, 47, 50, 52, 53, 58, 313, and 365) who were mobile and able to access bathroom faucets. […]

• Actual harm, isolatedF684Sep 27, 2024

  Based on observation, interview, and record review, the facility failed to ensure a Finger Contracture Cushion (a fabric cushion made of breathable and absorbent material, with three large loops in the middle for: index, middle and third finger, and two tight rings on both ends. The cushion is used to separate the fingers and protect the palm), commonly known as a hand roll, was placed correctly on one of three sampled residents ' (Resident 1) left hand. Resident 1 was left unattended and unsupervised, when his pinky finger was tightly inserted in the last ring of the cushion, for over seven hours. […]

• Actual harm, isolatedF692Jun 9, 2023

  Based on observation, interview and record review, the facility failed to identify, monitor, and intervene for weight loss of seven (7) pounds (lbs.), 5.6% in one month, for one of two sampled resident (Resident 8) for more than one month. This failure resulted in Resident 8 to not receive an assessment and intervention to prevent further weight loss for one month and Resident 8 lost 1.8 more lbs. during that period. Resident 8 had a severe weight loss of 13.4 lbs. with a percentage of 10.31% within a period of three (3) months. […]

• No harm, potential for more than minimal, widespreadF812Jun 9, 2023

  Based on observation, interview, and document review, the facility failed to store, prepare, and serve food in a safe and sanitary manner when: 1. A blender was dirty 2. The chopper was not maintained in good condition. 3. Dry cereal was kept beyond use-by date. These failures had the potential to result in food-borne illnesses to 52 residents who receive food from the kitchen out of a facility census of 56 Findings: 1.During the initial tour of the kitchen on [DATE] at 8:15 am, with the Culinary Service Director (CSD), a blender on the countertop was observed with scattered food residue on the base and thick food residue inside the plastic container of the blender. […]

• No harm, potential for more than minimal, patternF684Mar 27, 2026

  Based on interview and record review, for one of four sampled residents (Resident 3), the facility failed to ensure care and services were provided according to professional standards of care when:a. Resident 3's multiple episodes of diarrhea, which represents a change in condition, were not reported to the physician.b. Resident 3's physician-ordered oral medications were not administered as ordered. Colace, a stool softener, was either held or refused repeatedly because of diarrhea, but loperamide, an anti-diarrheal medication, was not administered. This failure had the potential to result in delayed medical management, increasing the risk for dehydration, other serious complications and emotional distress.1. […]